Mental Illness Vignettes

Front 1

A 25-year-old female presents to her primary care physician with complaints of muscle tension, especially in her shoulders and neck, contributing to tension headaches. She describes decreased sleep, chronic fatigue and constant restlessness in addition to poor concentration at work, with repeated run-ins with her coworkers. She has been a worrier since childhood, with worsening bouts when under stress. Physical exam reveals a healthy, tense female with normal vital signs and generalized muscular tension. She does not abuse substances, and medical history is unremarkable.

Back 1

GAD

CBT
Buspar/Buspirone

Front 2

A 53-year-old female has longstanding social anxiety, dating back to childhood. She always feels shy and self-conscious around others, and never feels that she knows what to say or how to act. She has never dated, and reports few friendships over her life. She works as a computer programmer so that she does not have to interact with others face to face. She has passed up advancement opportunities at work as these would have placed her in a more interactive role with others. She often feels physically tense, nervous, nauseous, and flushed, even during casual interactions. After these situations, she will often replay these events in her head in an extremely self-critical manner. She spends most of her time alone and lacks social skills. She is sometimes described by others as "odd" or "a loner". She avoids almost all social situations.

Back 2

social anxiety disorder

CBT
benzo, beta-blocker, ssri

Front 3

A 22-year-old male in his freshman year of college reports increasing stress at school. Although historically he has done well academically and appears quite extroverted, the transition to college has been difficult and his grades have been suffering. He is afraid of drawing attention to himself in his classes by asking "stupid questions" and has avoided meeting with his professors and teaching assistants. He experiences particular difficulty in seminars and tutorials, where there is less opportunity to hide than in a lecture theater. He feels his mouth getting dry and his heart racing when even thinking about trying to get help. He has become more withdrawn, is starting to feel more depressed, and recently began missing classes.

Back 3

social anxiety disorder

CBT
benzo, beta-blocker, ssri

Front 4

A 32-year-old man presents describing an intense fear of germs. He continually experiences thoughts about contracting an illness by coming into contact with things in the environment, such as doorknobs or seats in public places. His intense fear of germs has resulted in repetitive hand washing. He describes brief relief after hand washing but, because his thoughts about contamination keep returning, he states that he "cannot help but wash again for hours a day." Both of his hands are red, raw, and cracked and he had to leave his job because of his fear of sitting down in public places. He has been taking a serotonin reuptake inhibitor since age 26 without any appreciable effect, and he has not recognized that his thoughts and behaviors were irrational. He also exhibits a high level of impulsivity.

Back 4

ocd

cbt
ssri

Front 5

A 45-year-old woman presents describing obsessive concerns that she has or will accidentally harm someone. Her most debilitating symptoms occur in the context of driving. She reports being troubled by obsessions and compulsions for approximately 4 hours each day. When she drives over a pothole or speed bump, she experiences overwhelming uncertainty about whether she may have accidentally run over a child. In an attempt to ease the anxiety she drives back and forth on her street in order to search for any indication that a child has been injured. When she completes these compulsions, she returns to her home and engages in checking compulsions for any evidence of blood or clothing under her car or on her tires. She then calls her husband repeatedly at work to ask for reassurance that she has not harmed anyone. Although she is aware that her concerns are irrational, she finds it very difficult to resist her impulses to engage in these rituals.

Back 5

ocd

cbt
ssri

Front 6

A 22-year-old woman in her first year of college reports waking in the middle of the night with a pounding heart, hot flushes, smothering sensations, and intense nausea. The attack came suddenly and unexpectedly, was not in reaction to a nightmare, and the symptoms subsided within a few minutes. Over the last few months, she is feeling more anxious and has experienced similar episodes each week at varying levels of intensity. She is worried that she might be on the verge of a "nervous breakdown" and admits to being overly aware of her "fast breathing and heart rate.

Back 6

panic disorder

cbt
beta-blocker

Front 7

A 38-year-old man presents to the emergency room for the second time in 4 weeks with sudden-onset chest pain, tachycardia, shortness of breath, dizziness, and sweating. He says he is afraid of having a heart attack and is afraid of "losing his mind." He is no longer driving his car and has started avoiding crowded areas for fear of inducing further attacks. Past medical history is unremarkable. Cardiac testing during both admissions is normal.

Back 7

panic disorder

cbt
beta-blocker

Front 8

“When Mandy gave birth to her second child, the birth was unexpectedly complicated, but the baby came home 3 weeks later.  One day, after her husband came home from work, Mandy raced down to the local supermarket alone, so she could quickly pick up a few items for dinner. That was when the first attack hit her. She couldn't breathe; her heart raced and felt like it would explode. Mandy's attacks continued to occur and Mandy quickly learned to avoid any situation where another attack could occur. Her daughter is now in school and Mandy is unable to take her there and relies on a friendly neighbor to take her daughter to school and back. Mandy seldom leaves the house and only in the company of her husband.

Back 8

panic disorder with agoraphobia

cbt
beta-blocker

Front 9

A 25-year-old woman presents to the emergency room complaining of sad mood, nervousness, difficulty falling asleep, and disinterest in her friends for the past 2 months. She notes these symptoms started following a rape by a former male friend after a party. She appears visibly uncomfortable when asked further questions about the attack. The patient has disclosed the incident to some of her peers, but did not report it to authorities. She reports nightmares about the rape, concerns for her safety, difficulties in intimate relationships with men, and repeated avoidance of nondangerous situations reminding her of the assault.

Back 9

ptsd

cbt
prazosin/minipress

Front 10

A 35-year-old male Desert Storm combat veteran presents to the office with symptoms of poor sleep, crying episodes, violent flashbacks, and nightmares. He also reports his marriage and friendships have been suffering, in addition to poor work performance. When in a bad mood, he tends to smoke cigarettes and drink alcohol. He has tried to overcome these symptoms on his own, but has been largely unsuccessful and now recognizes a need for formal help. He speaks openly about his experiences and recognizes a direct connection between his combat exposure and current symptoms

Back 10

ptsd

cbt
prazosin/minipress

Front 11

A 40-year-old man experiences intense worry several weeks before scheduled airline travel. However, he is required to fly several times each year with his work. His fear developed 2 years ago following an extremely turbulent flight. He has recurring, vivid images of himself dying in a fiery crash while flying. He is hyperaware of any sound and unexpected movement of the plane. Over the past several months he has been drinking alcohol excessively in an attempt to manage his symptoms.

Back 11

specific phobia

exposure/desensitization
benzo for short term

Front 12

A 25-year-old woman has panic-like symptoms when exposed to spiders, and experiences intense fear when confronted with anything resembling spiders. Her symptoms have existed for as long as she can remember. She rarely ventures into the garage or attic, and prior to going to bed each evening her husband must thoroughly inspect the bedroom. She admits she has never been bitten by a spider, is embarrassed about her reaction, and realizes that spiders are not always dangerous; however, she is flooded by fearful thoughts that all spiders are aggressive and threatening.

Back 12

specific phobia

exposure/desensitization
benzo for short term

Front 13

A 20-year-old man presents to the ER accompanied by his parents, owing to a change in mental status and behavior, marked by uncharacteristic argumentativeness, eruptions of laughter, excessive talking, and unusual thoughts. He is being treated for depression and insomnia, and has recently been drinking more alcohol. For the past 2 weeks, he has missed college classes, while staying up most nights until 4 or 5 a.m., writing feverishly into several notebooks. When asked, he reports that he is writing 2 novels at the same time and also documenting his accomplishments in an autobiography. He denies any illicit substance use while admitting to increasing alcohol consumption "like all the great novelists do." Efforts by his family to understand his recent change in thinking and behavior have been met with loud and rambling discourses, and he angrily accuses them of wanting him to stay "subjugated by the tyranny of depression."

Back 13

bipolar I

fam tx, talk tx, social skills
anticonvulsant, lithium, mood stabalizer

Front 14

A 32-year-old nurse presents to her primary care provider complaining of frequent headaches, irritable bowel, insomnia, and depressed mood. She currently takes no medication and has no history of substance abuse or major medical problems beyond treatment for a single depressive episode when she was a college freshman. Her physical exam, routine labs, and CT brain are all within normal limits. Her family history is notable for several ancestors who have been affected by psychiatric illness, including depression, bipolar disorder, and schizophrenia. Her paternal grandfather and a maternal aunt committed suicide. She has had 3 prior episodes of several weeks' duration characterized by insubordinate behavior at work, irritability, high energy, and decreased need for sleep. She regrets impulsive sexual and financial decisions that she took during these episodes, and has recently filed for personal bankruptcy. For the past month her mood has been persistently low, and she has had reductions in sleep, appetite, energy, and concentration, with some passive thoughts of suicide.

Back 14

bipolar I

fam tx. talk tx, social skills
anticonvulsant, lithium, mood stabalizer

Front 15

When seen next, Ms. A complained of continued hypersomnia and daytime lethargy, increased appetite, frequent crying, headaches, and memory problems. Increasing her fluoxetine dose from 20 mg to 40 mg seemed to help for a while, but then gradually stopped working—the same pattern of response noted on initiation of fluoxetine treatment. We asked her to describe the timing and quality of her initial improvement on the increased dose. After only 2 to 3 days on 40 mg of fluoxetine, she went from lying in bed much of the day to playing kickball in the backyard with her children. Her hypersomnia reversed abruptly to her needing only 3 to 4 hours of sleep per night. Ms. A described feelings of elation and of having her mind filled with ideas and activities, racing from one thought to another. She became markedly more talkative and social. Those around her noticed her behavior as distinctly different than usual. This sudden and dramatic response lasted about 1 week, ended suddenly, and was followed by a steady decline in energy and motivation over the next several weeks. When asked if these episodes had ever occurred in the past, Ms. A described experiencing similar brief periods of expanded mood that occurred every 2 to 3 weeks, typically lasting from 2 to 3 days, but occasionally as long as 5 days. She recognized these periods as being time limited and would try to make the best of them by shopping and doing housework, often late into the night.

Back 15

bipolar II

fam tx, talk tx, social skills
anticonvulsant, lithium, mood stabalizer

Front 16

A 22-year-old unmarried white man presents to the clinic with his mother. He spends most of his time in the house and refuses to go out at night alone. He used to live independently and worked until a few months ago. The patient states he made an error on his taxes and is convinced the Internal Revenue Service (IRS) hired detectives to gather information about his whereabouts. He states that since his mistake he uncovered an essential flaw in the taxation algorithm, which may expose the underpinning of IRS, and is convinced they hired assassins disguised as bikers. After moving in with his mom, he did not see the bikers, but they are trying to trace his "mental activity". Also, he hears them outside of his house talking about how they will kill him; he reported the problem to the police and FBI and is seeking my help "to defeat the IRS". He appears suspicious, avoids eye contact, and his answers to questions are delayed, during which he appears internally preoccupied.

Back 16

schizo

fam tx
atypical antipsychotics

Front 17

A 26-year-old African-American single woman is seen in the outpatient clinic with her mother. She is dressed provocatively and states that she is Whitney Houston's daughter and a very important person who knows many famous actors. Her thought content is significant for thought blocking. At times, she is observed to direct her attention to random parts of the room, presumably as a result of active auditory hallucinations. She also believes that everything that she thinks will, in fact, happen. The patient reports that she has always been shy, with few or no friends as she grew up. She started to experience perceptual disturbances around the age of 18, when she "saw spirits but did not hear them". Around that time she also became aware of her ability to know the future. For example, once she looked toward the airport and knew that 2 planes would crash in the future. She wanted to call someone to report it but did not know whom to call. Days later there were 2 accidents. Despite such unusual experiences she was able to train as a dental technician and had a steady job for 5 years. During that time, she started to experience more auditory hallucinations. She described them as voices conversing, at times yelling or giving her directions, even telling her to kill herself, when under stress. She also reported that she resisted the voices by distracting herself, as she did not want to die. Last year she also had a mixed episode, during which she was manic, did not sleep for more than a week, felt "hyper", impulsive, and "tingling", and also depressed. At that time she decided that she could not continue to work in the same place and left; she has not since held a job. At the time of her initial evaluations she was living with her parents and brother. About 1 year ago, she started an antipsychotic medication, which decreased the intensity of the voices and the fear that other people could read her thoughts. During the past year she has had manic symptoms most of the time (including grandiosity, impulsivity, decreased sleep, and mixed mood symptoms). This culminated with an exacerbation about 6 months ago that prompted psychiatric hospitalization. On examination, she was sitting in a somewhat provocative position on the couch. Her speech was high-pitched. She appeared relaxed, though at random times she would get tense. Her thought process was slow and tangential, with intermittent thought blocking. Her attention span was moderately diminished. No active suicidal or homicidal thoughts were present; however, she reported that the voices insisted that she should jump out of the window. Her insight and judgment were poor.

Back 17

schizoaffective

problem solving, socialization, & support
atypical for schizo; anticonvulsant or ssri depend on other symptoms

Front 18

A 48-year-old woman becomes convinced that her next door neighbor hates her and wants her to move. She states she has evidence, and when asked to explain, tells the psychiatrist that the neighbor gives her “looks,” puts excessive junk in her mailbox, and leaves yard clippings on her side of the yard to harass her.

Back 18

delusional disorder

cbt & social skills
atypical antipsychotics

Front 19

A 62-year-old man is arrested for disturbing people on their way to work by insisting they take his prepared reading materials with them. The topic of the materials was the man’s special communications with God and his instructions for following him on a special path to heaven.

Back 19

delusional disorder

cbt & social skills
atypical antipsychotics

Front 20

A 49-year-old man was arrested for beating up on his wife. He stated he had to punish her for having an affair—which she vehemently denied. The man’s wife states to the police that the man has accused her of being interested in many other men over the course of their marriage. He now seems fixated on the topic.

Back 20

delusional disorder

cbt & social skills
atypical antipsychotics

Front 21

Mrs B is a 43 year old housewife who went to see a clinical
psychologist with a chief complaint of being concerned about her “sex
problem”; she stated that she needed hypnotism to find out what was wrong
with her sexual drive. Her husband supplied the history: he complained that
she had had many extramarital affairs, with many different men, all through
their married life. He insisted that in one 2-week-period she had had as many
as a hundred different sexual experiences with men outside the marriage. The
client herself agreed with this assessment of her behaviour, but would not
speak of the experiences, saying that she “blocks” the memories out. She
denied any particular interest in sexuality, but said that apparently she felt a
compulsive drive to go out and seek other men despite her lack of interest.
The client had been married to her husband for over 20 years. He was
clearly the dominant partner in the marriage. The client was fearful of his
frequent jealous rages, and apparently it was he who suggested that she see
a clinical psychologist in order to receive hypnosis. The client maintained that
she could not explain why she sought out other men, that she really did not
want to do this. Her husband stated that on occasion, he had tracked her
down, and when he had found her, she acted as if she did not know him. She
confirmed this and believed it was because the episodes of her sexual
promiscuity were blotted out by “amnesia”. Mrs B could not be convinced
otherwise that she had actually had countless extramarital sexual
experiences, even though she did not remember any of them.
When the clinical psychologist indicated that he questioned the reality
of the wife’s sexual adventures, the husband became furious and accused the
clinical psychologist of having sexual relations with her.

Back 21

shared psychotic delusions disorder

psychotx
not needed b/c usually go away upon seperation from primary case

Front 22

A 2-year-old boy presents following concerns that he is not yet using single words. He also seems disinterested in engaging with other children. He occasionally engages with his parents but less than they think he should. He doesn't tend to look at them much and they have difficulty maintaining eye contact with him. When he wants something he pulls them to where the object is and screams; he doesn't point like other children. His parents have also noticed that he doesn't play in the same way as other children of his age; he tends to line toys up, or plays with certain aspects of them, such as the car doors. He doesn't use the toys in the imaginative way that other children do. When his toys are moved he becomes very upset. He tends to become distressed when he thinks there is change around the house. In contrast, he is not concerned when either of his parents leaves the house.

Back 22

Autism

fam tx, pivotal response training
only to treat symptoms like anticonvulsants for migraines

Front 23

A 3-year-old girl presents because her parents are concerned about her language development. She started using single words at age 18 months but still doesn't use 2 words together. She stopped using words she had previously learned between 18 and 24 months, but has now regained most of these words. She does use words to request and she points at objects, but doesn't look at her parents when she does this. She plays with toys but prefers to play alone. She is less interested in other children than expected. She plays with her parents but only does this when they bring toys or books to her. She screams when taken to the supermarket and doesn't like noisy environments. She tends to flap her hands at times and her parents report her staring at the ceiling lights for 10 to 20 minutes at a time. She is a fussy eater and hates being messy.

Back 23

autism

fam tx, pivotal response training
only to treat symptoms like anticonvulsants for migraines

Front 24

A 12-year-old boy is referred for assessment because of bullying by his peers at school. He is described as academically bright and, apparently, obsessed with steam trains, of which he has an encyclopedic knowledge. His parents report that he will spend all his time engaged in this interest, often skipping meals, and that he will only engage in conversation if focused on his interest. Otherwise he is quiet and shows no interest in or inclination to be with others, including his peers. He has always tended to shun social interaction and conversation. He prefers to have a routine, the disruption of which can result in tantrums. As a result of his difficulties he has not made friends and is laughed at because of his odd posture and gait and his tendency to speak very loudly and monotonously.

Back 24

aspergers

fam tx
only for any commorbid like depression or any symptoms

Front 25

A 24-year-old filing clerk at the local library is referred for assessment as a result of increasing tearfulness. He has recently graduated in computer science at university and was offered this job as he knows the librarians well, having spent most weekends at the library throughout his life. He reports never having made friends throughout school or university, and describes feeling lonely as a consequence. At assessment he presents as reasonably well-kept but dressed in a somewhat old-fashioned and quirky manner, and uses eye contact only fleetingly. His speech is monotone with rapid explosive bursts making it difficult to understand what he is saying. Throughout the assessment he fails to elaborate on anything without prompting. He only becomes animated when talking about artificial intelligence in computer technology, not recognizing that his assessor does not understand and is not particularly interested in this topic.

Back 25

asperger's

fam tx
only for commorbid like depression or any symptoms

Front 26

A 7-year-old boy is brought to the physician's office because of difficulty at school and behavior problems that started when he was in preschool. His mother reports that at home he runs around all day, needs multiple requests to pick up his toys, and can only sit still for a few seconds before growing bored. A teacher's note states that he cuts in line, distracts his classmates, and loses his homework assignments but is able to finish his work when he is given individual supervision. His mother is concerned because other children are teasing him for being stupid. However, she reports that he is a good boy who does not talk back to teachers or adults and does not bully anybody. In the office, he is jumping up and down in the chair despite multiple requests by his mother to sit still. She notes that his 15-year-old brother was also hyperactive when he was younger and has persistent academic problems.

Back 26

ADHD

beh training, parent management train, school training
stimulants long or short

Front 27

A 12-year-old girl presents to the physician's office because of problems with school performance. She attends a large public high school, and her teacher has reported that she has not been turning in her assignments and she is falling behind in math. Her father hired a tutor, and she seems to respond well to individual instruction. In the office, it is noted that she is sitting calmly but is constantly fiddling with her cell phone and is distracted by the toys in the room. She says that she does fine on tests but has difficulty focusing on homework. She still maintains an active social life and reports that her mood is fine.

Back 27

ADHD

beh training, parent management train, school train
stimulants, strattera SNRI, antihypertensive guanfacine

Front 28

Ken is a 10-year-old boy who has been referred to a
psychologist because of a recent escalation in his ongoing behavior problems. At preschool age, Ken began
throwing temper tantrums, talking back to his mother,
and acting disobediently. His mother frequently received
calls from his teachers during his early school years for
problem behavior. Ken is frequently sent to the principal’s office for being disruptive in the classroom, talking
back to the teacher, and getting into fist fights with other
children. Ken has few friends and spends a lot of time
playing alone. Recently, Ken was picked up by police
because he was found setting a fire in an abandoned
warehouse. This prompted his mother to seek help by
contacting the school psychologist who referred him to
a specialist in the area of disruptive behavior disorders.
Ken’s mother is very concerned about his problem behaviors and whether it is a sign that he will be “a
criminal” as an adult. T

Back 28

oppositional defiant disorder

parent management training
not typically used; stimulants if also have ADHD

Front 29

"Jason," age 17, currently lives in a residential treatment facility for emotionally troubled teenagers. His "file" indicates that as early as the third grade, Jason was labeled as the class bully and often initiated physical fights with peers. During middle school (age 12) he began skipping school and "roaming the streets" at night while using marijuana and alcohol(. He was once confronted by a store clerk as he tried to steal a pair of sneakers. In retaliation he spray-painted obscenities across the clerk's car and tossed a brick through the windshield.

When he was 15, Jason attacked a woman with a broken bottle and took her car keys. He was subsequently arrested after her car was traced by the police and he was court-ordered into a locked residential treatment facility.

Back 29

conduct disorder

parent management training
lithium for drug cravings
methylphenidate patch
antihypertensive clonidine
anticonvulsant carbamazepine or valproic acid

Front 30

Dale's first enquiry is whether I am in any way associated either with the government or with his former employer. He doesn't seem reassured by my negative response. He eyes me skeptically and insists that I inform him if things change and I do become entangled with his persecutors. Why do I treat him pro bono? He suspects some ulterior motives behind my altruism and inexplicable generosity. I explain to him that I donate 25 hours a month to the community. "It's good for your image, gives you access to local bigwigs, I bet." - he retorts, accusingly. He refuses to allow me to tape record our conversation.

I set some boundaries by reminding him that the therapy session is about him, not me. He nods sagely: it's all part of an intricate scheme to "subdue" him and place him "under firm control". Why would "they" want to do that? Because he knows too much, having exposed fraud, lies, and deceit in the highest places. He has done all this from his position as a sanitary worker at the municipality? - I enquire. He is visibly offended: "There are more secrets in people's trash than in the CIA!" - he exclaims - "You think that your academic degree makes you more clever than I am or somehow superior to me?"

When was the last time he went out with friends? He has to think hard to come up with an answer: "Four years ago." Why so long? Is he a recluse by nature? Not at all, he is actually gregarious. So, why the social isolation? Part of his defense. You never know when something you have said in company will be used against you. His so-called friends have been asking him too many intrusive questions lately. They insisted on meeting in new venues at odd times and he got suspicious.

So, what is he doing all alone at home? He laughs bitterly: "Won't they love to know my next moves!" He isn't going to give them the pleasure of evincing his strategy. All he is willing to say is that "they" will pay dearly for having underestimated him and for having turned his life "into a long nightmare in hell". Who are "they"? His superiors at the sanitary department. They reassigned him to a dangerous part of town, working night shifts, effectively demoting him from team foreman to "common janitor". He will never forgive them. But wasn't this a temporary arrangement owing to manpower shortages? "That's what they said at the time"- he admits reluctantly.

Back 30

paranoid pd

psychotx
lose dose antipsychotics

Front 31

Jacob is a 26 years old man. Despite extraordinary intelligence John was not able to complete or participate in any educational program. He wanted to have a normal life with a family and friends, but thought that he was rootless and he felt that other people thought that he was peculiar or odd. He felt that he was outside. As a child he went to various schools because his parents moved around. He was thought of as a lonely wolf and did not participate in the social life or games of sports with his peers. During school class he was often absent minded being absorbed in his own thoughts and fantasies. From around the age of thirteen he became interested in computers and was quite advanced in his understanding of mathematics. He became exceedingly isolated with his computer as his sole companion.

Back 31

schizoid pd

psychotx or group tx for social skills
risperidone for blunt affect & social deficits

Front 32

A 37 year old, unemployed man claimed of recurrent irrational thoughts, compulsive behaviour, and social isolation. Since his childhood he had always been eccentric, withdrawn with no real friends anxiously fearing closer relationships, preoccupied with reading stories about Dracula and other myths. He didn’t share his inner thoughts or feeling with anybody, including his parents. He never finished an education, but worked in factories, often at night. Some years earlier he started doubting if his work was accurate enough. Although he recognized these thoughts as irrational, he started spending a lot of time controlling his work over and over again. Soon these compulsive controls took so much time that he could not finish his work, was continuously annoyed by intrusive vivid homosexual images, was preoccupied with doubts concerning almost everything at home and also he had to look persistently at people in order to be sure to maintain their images in his memory. He started fearing that people could notice his behaviour, and he felt that unknown people was staring at him and that they secretly were making fun of him. He complained of being unable to reveal his feelings and thoughts to other people and felt isolated. He started drinking alcohol to control his increasing anxiety. He adopted different peculiar strategies, which ended in new vicious circles of obsessive symptoms and suspiciousness.

Back 32

schizotypal pd

psychodynamic
antipyschotics

Front 33

This is a 27 year old male who committed murder at age 17. He stayed in a high-security hospital for 10 years and started individual treatment after being released. He was an intelligent boy who did well in school until his peers began to tease him. This made him feel helpless and unable to defend himself. At home, however, he felt strong and supportive of his mother. His father lived with another woman. He experienced him self as a looser among his pears but as a winner with his mother. At the end of primary school his father, who then had accumulated substantial wealth, returned home, and the parents resumed their marriage and intimacy. His situation at school changed as he became popular and the teasing stopped, but he still felt insecure and uneasy. He decided to attend karate school to gain a sense of power. A peer introduced him to the criminal milieu where he felt accepted and appreciated. During a robbery he became incredible angry and physically violent without really understanding why. The victim died as a consequence of his attack. He was send to prison for 2 years, followed by a high security hospital for treatment. While he accepted his prison sentence he protested treatment in psychiatric hospital. He was suspicious, remained non-relative and was often restrained due to anger outbursts. A therapist confronted him with the fact that his behaviour could lead to prolonged hospital stay and pointed to his choice of future inside or outside the hospital. This was turning point that made him focus on goals and training for a future out in real life. After discharge he continued to work on self-esteem and trustworthiness, shame and guilt and how to understand, control and come to terms with his anger. Two years later he was married with a son, and pursued a career as a teacher.

Back 33

antisocial pd

psychotx or fam tx
only to treat symptoms; antipsychotic or mood stabalizer

Front 34

A 23 years old woman reacted with depressive symptoms and suicidal thoughts to the death of her grandfather. She was treated with antidepressant medication without addressing the loss. Three years later after a suicidal attempt, she was admitted to hospital where she first presented with depressed mood and suicidal thoughts, but quickly engaged in vivid conversations with the others patients. She was discharged with the diagnosis of personality disorder, but soon re-admitted because of suicidal thoughts, and referred to an outpatient program specialized on treatment of personality disorder. Since childhood she had unstable mood, aggressive temperament and self-destructive behaviour (head banging). At the age of 10 she was sexually abused by an older man. Suicidal thoughts and urges to kill herself was first experienced at age 11. Since age 13 she has had multiple sexual partners but also one 7 year long relationship which was quite unstable with frequent conflicts and impulsive acts. She dropped out of school and has been living on sickness benefits, interrupted by short periods of unskilled employment. In a two year psychoanalytic treatment program with one individual session and one group session a week in addition to psycho education, she worked together with other patients on identifying and understanding the characteristic features of BPD, and the dynamics of borderline pathology with a special focus on self-destructive behaviour. Her self-destructive behaviour tapered off after 3 months as she began to process her feelings of aggression and sadness. The pharmacological treatment terminated after 6 months and she quickly became less sedated and anxious. She resumed school towards the end of the first year of treatment, with the intention of taking a degree in teaching. The relationship with her boyfriend stabilized. Contacts with class became more satisfying, and conflicts with her teachers stopped. Her ability to begin to contain feelings increased dramatically.

Back 34

borderline pd

dbt
ssri

Front 35

A 42-year-old male professional in public office, was forced to resign after being arrested when visiting a brothel. In the aftermath he suffered from depression and considerable alcohol consumption, and was admitted for a three months treatment. He stopped drinking, but his depression remained nonresponsive to anti-depressant medication. Still without meaningful activities he felt empty and restless, and he was referred to psychotherapy. Developmental history indicates that at age 5 his father left the family, and they did not meet until he was in law school. He was always ahead of his age and went through school without difficulty. In law school he got high marks without hard work. He had many acquaintances but no friends, and he felt like an outsider. He got married and had two children. Reaching mid-thirties he felt bored. He had everything: house, career, and family. He was respected and accomplished, but felt he didn’t belong. He started drinking heavily and visiting brothels. The psychotherapist found him self-assured, easily irritated, and quick to make devaluating remarks, and felt a mixture of irritation, compassion and powerlessness. Interactions during weekly appointments were extremely difficult. Unwilling to explore his situation or his feelings, he blamed the therapist for the impasse and told him that he will not change and that the therapist could not help. The therapist dreaded the appointments, while the patient despite finding the sessions unhelpful, always showed up. When the therapist announced a three weeks break his patient suggested the treatment to end and did not return. Nine months later he informed the therapist that he moved to another city, had a leading position working with international trade, and was greeted as a king. He said nothing about his wife and children. Nor did he indicate how he felt about the treatment.

Back 35

narcissistic pd

psychodynamic & cbt
ssri for possible anxiety or depress

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A 25-year-old female university student sought psychoanalytic treatment as she suffered from depression, difficulties in interpersonal relationships, and vocational dissatisfaction. Her first panic attack occurred during the last year in high school when her boyfriend was treated for panic attacks. She believed she was "influenced" by him. In psychotherapy she overcame family difficulties, especially in relation to her mother, but continued to feel insecure and pessimistic, blaming it all on her boyfriend. Their conflictual relationship ended when she had an episode of depression. She felt she wanted to die and sought consultation for psychoanalytic treatment saying that she was wasting her life, and lacked motivation for studies or career. She dreamt about her former boyfriend, and after breaking up with two other men she felt extremely lonely. She is the third of seven children. The father was hard-working, affectionate and caring, but also irritable and depressive. The mother was impulsive and sarcastic. Mother and daughter had a close but conflictive relationship as the mother could be intrusive, opinionated and idealizing. At age three the parents moved abroad for one year and left her to live with relatives. Upon their return she was presented to a baby brother. Significant sensitivity during her school years led her to break up friendships and feel extremely lonely. She did well at university, formed friendships but noticed that she often felt rejected without knowing why. In psychoanalysis four times per week she presented several contradictions, i.e., pursuing treatment and lapsing, or describing her mother as unsupportive, cold and envious but nevertheless readily resorting to her when facing difficulties. As the psychoanalysis progressed she presented infantile histrionic features; a precarious identity, strong affective dependence, dissociation, infantilization and self destructive work related behaviour. She brought multiple dreams to the sessions and gave vivid images of conflicts that worried her. Despite efforts to interpret, the analyst noticed no progress. Paradoxically, her presentation of dreams and associations indicated in-depth psychological work, but her persistent tardiness and absenteeism reflected the opposite. After eight months of psychoanalysis, the analyst suggested 3 sessions per week of face to face psychotherapy and referred her to a colleague.

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histrionic pd

psychotx
ssri for possible anxiety or depress

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The patient was a 35 year old, unmarried data technician referred to a specialized treatment program for personality disorders from an out-patient drug addiction service. His personality pathology was considered more devastating than his substance abuse. Presenting complaints included low self esteem, loneliness, sense of emptiness, suicidal ideation, social isolation, substance abuse, general dissatisfaction with life. Present complaints had been chronic in nature, dating back to childhood. He recalled having daily suicidal thoughts for several years in his early youth. On axis I he fulfilled the criteria for dysthymic disorder and drug abuse in partial remission, but not panic disorder or social phobia. His avoidant behavior was more prominent than his level of experienced anxiety. On axis II he fulfilled all seven criteria for avoidant personality disorder and an additional seven criteria spread across other personality disorders. The most prominent feature was a pervasive fear of being ridiculed when interacting with others. In a group-based treatment program lasting for 20 weeks, he was a regular, but somewhat detached participant. The therapists encountered a series of problems related to passivity: He postponed most of his obligations, resisted sorting out practical affairs, did not pay his bills and avoided contacting people who could be helpful.

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avoidant pd

group tx or fam tx
ssri or benzo like klonopin

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The patient was a 27 year old white female administrative assistant whose work required much use of the computer and data entry. She gradually began to develop pain in her wrists. Physicians diagnosed a potential carpal tunnel syndrome. The damage to her wrists was not reparable by surgery and Sally was left in significant daily pain. The patient demonstrates the key aspect of Dependent personality, the need to please others even at the expense to herself. The degree to which her self-destructive passivity and compliance at work stemmed from her early experiences within the family are unclear, but her parents’ overprotectiveness likely played some role in the etiology of her personality pathology. Research confirms that overprotective and authoritarian parenting, alone or in combination, often lead to excessive interpersonal dependency in offspring.

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dependent pd

psychotx w/ assertiveness training
med only for axis I diagnosis

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The patient was a 42-year-old single male, who lives with his parents. He has been unemployed for some time. He presented to the anxiety disorders clinic at a major teaching hospital, because of concerns regarding his long-term unemployment. He tended to procrastinate when making decisions or carrying out plans. On weekends, when the family planned to visit the grandparents he would start packing on Friday afternoon, but on many occasions did not finish the packing until Sunday, by which time it was too late to go. He spent long periods of time in the bathroom, would take half an hour to wash his hands-first washing the tap, then his hands, then the tap again. This routine also made it difficult for him to go out and look for job. In fact, it totally prevented him from doing so. After leaving school, he has had 30 or 40 jobs, mostly factory work. The longest he has lasted in a job has been one week, often only one day. He was very punctual in treatment and never missed a session; he talked freely, and in great detail. The initial part of therapy mainly dealt with family relationships. When the time came to leave the sessions he would often continue talking and delaying even when the therapist was standing at the door.

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ocpd

cbt
ssri

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http://www.dailymotion.com/video/xo6km4_adjustment-disorder-with-anxiety-sample-training-title_tech#.UW8M0isjoVk

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many adjustment disorder videos online

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Mrs. A, a 91-year-old widowed Caucasian woman in good general health, was seen by her family physician for complaints of "forgetting things a lot lately." Mrs. A’s daughter, who often helped her mother with household chores, had noticed a change in her mother’s thinking and behavior over the past two years. "Mom used to be sharp as a tack and never forgot a thing," she reported. "Nowadays, she has trouble remembering even simple things, like turning off the stove, or in what room she keeps all her bills and papers. The other day, I found that she had left the bath running for over an hour, and it flooded the whole upstairs. Sometimes, Mom confuses me with her sister, who died over twenty years ago. When I try to explain who I am, Mom sometimes gets kind of irritable with me, and says I’m trying to confuse her." There was no history suggestive of stroke, sudden change in mental status, or loss of gross motor or sensory function. On mental status exam, the patient was pleasant, socially appropriate, and in no acute distress. She was oriented to the year, but not to month, day, or date. She recalled only one word item after three minutes. She could not remember the name of the two most recent U.S. Presidents, but was able to speak knowledgeably about the Presidents during the U.S. Great Depression (1929-1941). When asked to name three objects on the physician’s desk (stapler, paper clip, and calendar), she named them as "stapler, paper grip, and day book." A

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dementia

fam tx
ssri for depress
atypical antipsychotics to improve sleep
stimulants for focus

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http://www.learnaboutdelirium.com.au/index.php?option=com_content&view=section&id=10&layout=blog&Itemid=76

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delirium videos

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A 67-year-old teacher suddenly became amnestic after walking her dog. Her husband noted that she was oriented to person and knew the names of close friends; however, she was disoriented to time and place and seemed perplexed. She could follow complex commands but was unable to recall something she had been told 5 minutes before. The episode resolved after 10 hours, although she remained largely amnestic about the event. She had migraine without aura, but the episode of amnesia was not associated with headache. Her mother had a similar event after a traumatic experience. During and after the event, neurologic examination was normal. Computerized tomographic brain imaging, Doppler ultrasound of the extracranial cervical vessels, and electroencephalography were normal.

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amnesia

time
fam tx or vocational tx possibly

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http://symptommedia.com/adjustment-disorder-with-anxiety-sample-film/

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adjustment disorder with anxiety

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nicky is a 16yo girl who lives with her mother & had been attending grade 9. over the past 2 months, nicky exhibited depressive symptoms characterized by tearfulness & disrupted sleep patterns. nicky and her mother were evicted from their apartment 4m ago & spent several weeks at a homeless shelter. nicky is now worried that her mother will kick her out of the house because nicky recently turned 16 and her mother has been making comments that nicky should find a job. nicky and her mother fight constatnyly. she denies suicidal ideations & spends most of her days isolated in her room

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adjustment disorder with depressed mood

cbt
ssri for depresion & anxiety